General Intake Form Last Name(Required) First Name(Required) Age Range(Required) 16-20 21-30 31-40 41-65 66-81 82 and above Are you a U.S. Citizen? Yes No If no, are you a permanent resident? Yes No ITN#: Street Address Cit/State/Zip County Current Living Situation (check one) Homeless Living with Someone/Others Living Alone Total Members in Household Home PhoneMobile PhoneEmail Gender Female Male Other Prefer Not to Disclose Marital Status Single Married Divorced Widowed Race African American/Black Caucasian/White American Indian and Alaska Native Asian Native Hawaiian or Other Pacific Islander Ethnicity Hispanic Non-Hispanic Are you a U.S. Veteran? Yes No Highest Level of Education CompletedHigh school or GEDAssociate degreeSome collegeBachelor's degreeMaster's degreeDoctorateHave you been convicted of a felony? Yes No or Misdemeanor? Yes No Job Position Desired: Current or Previous Employer: Are you receiving SSI? Yes No Monthly income: $ Employment Status: (check all that apply) Full Time Part Time Unemployment (Due to COVID-19) Unemployed (Quit/Fired) No income Retired Self – Employed KAUL Services Needed: Housing Workforce Programs Education & Youth Services Economic & Business Development Justice and Advocacy Health Additional Support Services Needed: Transportation Alcohol & Drug Recovery Treatment Mental Health Counseling Child Support Legal Services Driver’s License/ID Financial Education Workforce Skills Training Computer Training Other Have you received services from KAUL before? Yes No Are you a registered voter? Yes No How did you hear about KAUL? TV Radio Newspaper Friends/Family Walk-In Social media/KAUL Website Other CAPTCHA Δ